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Long-Term Use of Some Antipsychotics Not Warranted in Older Adults: Study

WEDNESDAY, Nov. 28 (HealthDay News) -- The safety and
effectiveness of four drugs commonly used to treat older adults
with schizophrenia, dementia, bipolar disorder and other mental
health conditions are being called into question by a new
study.

The drugs -- aripiprazole (Abilify), olanzapine (Zyprexa),
quetiapine (Seroquel) and risperidone (Risperdal) -- are among
medications called atypical antipsychotics and are approved by the
U.S. Food and Drug Administration to treat schizophrenia and
bipolar disorders.

But physicians often pen off-label prescriptions for people with
dementia, post-traumatic stress disorder (PTSD) and other mood
disorders to help alleviate symptoms of psychosis as well as
anxiety, agitation and aggression.

The medications have been in use since the early 1990s.

The new study, published in the Nov. 27 issue of the
Journal of Clinical Psychiatry, involved 332 patients older
than 40 who had been diagnosed with an indicated mental health
condition and had psychotic symptoms.

"We wanted to see if these drugs were effective and safe for a long period of time," said study author Dr. Dilip Jeste, president of the American Psychiatric Association and a distinguished professor of psychiatry and neuroscience at the University of California, San Diego. He said the risk of cardiovascular disease increases in midlife, and previous research has suggested that this class of drugs can up cardiovascular health risks.

"This is a population in which these drugs are commonly used and in whom the risk of cardiovascular disease is high, and there was no long-term data comparing the drugs," Jeste said. Even though the newer drugs aren't indicated for long-term use except in schizophrenia and bipolar disorder, in practice, Jeste said, they tend to be taken off-label for extended periods of time -- sometimes years.

The scientists asked patients and their physicians to choose
which of the four antipsychotic drugs they would prefer to take.
They had to select at least two so they could be randomly placed
into a drug group. The researchers also left dosing up to the
clinicians, and doses could be altered at any time based on a
patient's needs.

Only about 17 percent of the participants and their doctors
agreed to be randomly assigned to all four drugs, with most citing
concerns about side effects.

Participants were given medical exams, including
waist-circumference measurements, and their health histories,
medication use and previous experience with drug side effects were
recorded. Follow-up assessments were repeated at six and 12 weeks
and then every 12 weeks over a five-year period.

Jeste said they were expecting that one or two drugs would
emerge as safer and more effective long term; instead, people
stayed on their medication for an average of only six months. The
percentage of patients who stopped their medication before the end
of the two-year follow-up period ranged from nearly 79 percent on
quetiapine to 81.5 percent on aripiprazole.

"We expected the patients to stay on the drugs for two years, but they stopped them due to adverse effects or a lack of improvement," Jeste explained. "That means the antipsychotic to which they were randomized did not work. Significant side effects were often to blame."

The study for one drug, quetiapine, had to be discontinued
altogether after three and a half years. "We had twice as many
serious adverse side effects midway through the trial with
quetiapine," Jeste said.

Serious adverse events included death, hospitalization for
pneumonia and other disorders, and emergency room visits for
problems such as confusion, disorientation and markedly
disorganized behavior. Less-serious side effects included
restlessness and agitation, drowsiness, and constipation or
diarrhea.

Another concern was the rise in risk for developing metabolic
syndrome -- a collection of symptoms that can increase a person's
odds of developing heart disease and diabetes. Metabolic syndrome
means a person has at least three of these signs: elevated blood
fat levels, low "good cholesterol," elevated blood sugar, large
waist circumference and high blood pressure.

In the study, one-third of the patients developed metabolic
syndrome within a year.

Dr. Lon Schneider, professor of psychiatry, neurology and
gerontology at the University of Southern California Keck School of
Medicine, was intrigued by the study's findings.

"This was a pragmatic study with good design and the main findings are enlightening about the extensive level of adverse events and the very limited efficacy of these drugs," said Schneider, who wrote a commentary on prescribing antipsychotic medicine in the August issue of the journal Clinical Neurology News.

Schneider said the new study confirms what has been seen in
effectiveness trials and in observational studies.

"The important information that it adds is the considerable level of adverse events," he said. "The study shows that when drugs are compared head to head, there is a high level of discontinuation due to intolerability. You don't see this in the pharmaceutical company placebo control trials."

Another expert said the new findings are not surprising.

"There have been concerns about the efficacy of these antipsychotic drugs for a long time," said Dr. Dan Blazer, chairman and professor of psychiatry at the Duke University School of Medicine. He added that this research will "put more pressure on the brakes."

"[But] there are individual patients in whom these types of drugs can make a big difference," Blazer said. "The issue is caution in using them."

Blazer and Schneider both warned that the danger is in using
them as a "chemical straitjacket," which can happen in nursing
homes and private homes when caregivers aren't always
available.

There are no magic bullets to treat agitation and aggressive and
threatening behavior, but there are alternatives to prescribing
drugs, such as cognitive behavioral therapy, Schneider said.

Jeste concluded: "The practical implication of our research is
that we should be very careful in using any of these drugs in
people over 40, especially if we are using them off label for any
length of time."

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.